Facilitators and barriers in pain management for trauma patients in the chain of emergency care

The use of strong analgesics for prehospital pain management in children in the region of Southern Denmark: a register-based study

BACKGROUND

Acute pain in the prehospital setting is frequent and prehospital pain management presents multiple challenges, especially in children. There is a lack of high-level evidence regarding prehospital pain management in the paediatric population worldwide. In Denmark, this lack of evidence particularly concerns the frequency of the prehospital use of strong analgesics. Guidelines are sparse but there is evidence that prehospital fentanyl may be administered up to 5 µg/kg.

METHOD

This register-based study investigated the prehospital analgesic treatment in the population under 15 years from January 2017 to December 2022 in the Region of Southern Denmark. Data were extracted from electronic prehospital medical records. The analgesic treatment was characterised by the type of medication, dosage, administration method, and cause of ambulance dispatch. Lastly, response- and transport times were registered.

RESULTS

A total of 28,933 prehospital paediatric medical records were examined. In one in seventeen of all prehospital contacts with children, fentanyl, alfentanil, morphine and/or s-ketamine was administered. Three-quarters of the doses of strong analgesics were administered to patients older than 10 years. Fentanyl was the most frequently administered medication (96.4%). The median fentanyl-equipotent doses of opioids were 1.7 µg/kg adjusted according to standardised patient weight. In 63.4% of cases, the analgesic treatment was administered intravenously.

CONCLUSION

The doses of opioids as administered by the EMS personnel seem safe as 97% of the doses were within the recommended range and even at the lower end of the recommended range. Although apparently safe, the utilisation of strong analgesics points to a risk of under-treating pain in children.

Paramedic Education and Training for the Management of Patients Presenting with Low-Acuity Clinical Conditions: A Scoping Review

Ambulance services around the world are increasingly attending to calls for non-emergency conditions. These lower-acuity conditions do not always require patients to be transported to the emergency department. Consequently, over the past two decades, ambulance services have implemented strategies to support paramedics in diverting non-urgent patients to alternative care pathways. However, assessing and managing low-acuity conditions can be challenging for paramedics, especially when education and training has traditionally focussed on emergency care. This scoping review explores the education and training provided to paramedics on low-acuity clinical conditions and the use of alternative care pathways. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews was applied. The databases searched included Scopus, CINAHL, Embase, Emcare, and MEDLINE (PubMed). The search identified one-hundred sixty-six records, with a total of nine articles reviewed after the removal of duplicates and the screening process. The articles were diverse, with education and training ranging from university degrees for extended care practitioners to short in-service-based training for a suite of protocols or assessment tools. However, the literature addressing education and training on low-acuity conditions and alternative care pathways is limited, with the type and length of education programs appearing to influence practice. There is a need for further research to establish a low acuity education model.

Missed nursing care in emergency departments: A scoping review

BACKGROUND

Patient safety is a global health priority. Errors of omission, such as missed nursing care in hospitals, are frequent and may lead to adverse events. Emergency departments (ED) are especially vulnerable to patient safety errors, and the significance missed nursing care has in this context is not as well known as in other contexts.

AIM

The aim of this scoping review was to summarize and disseminate research about missed nursing care in the context of EDs.

METHOD

A scoping review following the framework suggested by Arksey and O'Malley was used to (1) identify the research question; (2) identify relevant studies; (3) select studies; (4) chart the data; (5) collate, summarize, and report the results; and (6) consultation.

RESULTS

In total, 20 themes were derived from the 55 included studies. Missed or delayed assessments or other fundamental care were examples of missed nursing care characteristics. EDs not staffed or dimensioned in relation to the patient load were identified as a cause of missed nursing care in most included studies. Clinical deteriorations and medication errors were described in the included studies in relation to patient safety and quality of care deficiencies. Registered nurses also expressed that missed nursing care was undignified and unsafe.

CONCLUSION

The findings from this scoping review indicate that patients' fundamental needs are not met in the ED, mainly because of the patient load and how the ED is designed. According to registered nurses, missed nursing care is perceived as undignified and unsafe.

Patient, family member, and ambulance staff experiences of prehospital acute pain management in adults: A systematic review and meta-synthesis

Background

We aimed to synthesize the qualitative experiences of patients, their family members, and ambulance staff involved in the prehospital management of acute pain in adults and generate recommendations to improve the quality of care.

Methods

A systematic review was conducted following the enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) guidelines. We searched from inception to June 2021: MEDLINE, CINAHL Complete, PsycINFO and Web of Science (search alerts were screened up to December 2021). Articles were eligible for inclusion if they reported qualitative data and were published in the English language. The Critical Appraisal Skills Program for qualitative studies checklist was used to assess risk of bias, thematic synthesis was performed on included studies and recommendations for clinical practice improvement were generated.

Results

Twenty-five articles were included in the review, representing over 464 patients, family members, and ambulance staff from 8 countries. Six analytical themes and several recommendations to improve clinical practice were generated. Strengthening the patient-clinician relationship by building trust, promoting patient empowerment, addressing patient needs and expectations, and providing a holistic approach to pain treatment is key to improving prehospital pain management in adults. Shared pain management guidelines and training across the prehospital and emergency department intersection should improve the patient journey.

Conclusion

Interventions and guidelines that strengthen the patient-clinician relationship and span the prehospital and emergency department phase of care are likely to improve the quality of care for adults suffering acute pain in the prehospital setting.

Paramedic Education to Support the Use of Low-Acuity Care Pathways: A Scoping Review Protocol

Ambulance services worldwide have transformed over time into health care services that not only attend to life-threatening emergencies, but are also increasingly being utilised for patients with low-acuity or non-urgent illness and injury. As a result, there has been a need to adapt and include mechanisms to assist paramedics in the assessment and management of such patients, including alternative pathways of care. However, it has been identified that education and training for paramedics in the care of low-acuity patients is limited. This study aims to identify potential gaps in the literature and inform further research, paramedic education and training, patient care guidelines, and policy. A scoping review will be conducted utilising the Joanna Briggs Institutes methodology. A range of relevant electronic databases will be searched along with the grey literature, using search terms related to paramedic education for low-acuity patient care pathways. The search results will be screened by two authors and presented in the PRISMA-ScR format, with articles presented in tabular format and analysed thematically. The results of this scoping review will inform further research exploring paramedic education, clinical guidelines, policy and experiences in the management of low-acuity patients.

Pre-hospital analgesia in pediatric trauma and critically ill patients: An analysis of a German air rescue service

BACKGROUND

Pain management in the pre-hospital setting remains a particular challenge for paramedics and emergency physicians, especially in children. This study evaluates the pre-hospital use and effect of analgesics in children with trauma or pain due to other reasons.

METHODS

This study is a retrospective analysis of the database of a German air rescue service and was conducted over a period of 9 years (2012-2020) to assess pain in general and whether patients with trauma pain due to other reasons received treatment with analgesics. We included all patients in the registry under the age of 16 years. Patients with a Glasgow Coma Scale of 3 at hospital admission and incomplete records were excluded. The intensity of pain was determined by the emergency physician on scene at arrival and hospital admission in a ten-point rating scale (0 = no pain). Effective pain reduction was analyzed.

RESULTS

Out of 227,458 cases, a total of 22,025 emergency cases involved pediatric patients aged 0-16 years. 20,405 cases were included in the study. 12,000 (58.8%) children had suffered a trauma, 8108 (39.7%) had pain due to other reasons and 297 (1.5%) had both. In total, 4,608 (38.4%) of the children with trauma were assessed having a numerical rating scale (NRS) > 4 at EMS arrival. These patients received mainly ketamine (34.5%) and the opioids fentanyl (38.7%) and piritramide (19.1%). The value on the NRS was significantly lower at admission to hospital (mean 1.9) compared with the EMS arrival (mean 6.9). In 4.9% the NRS at hospital admission was still > 4. 282 patients within the non-trauma group had a pre-hospital NRS of > 4. The pain therapy consisted of opioids (35.8%) and ketamine (2.8%). 28.4% patients in the non-trauma group received no pain medication. In 16.0% the NRS at hospital admission was still > 4.

CONCLUSIONS

German emergency physicians achieved a sufficient pain therapy in pediatric patients with a NRS > 4 after trauma. In case of non-trauma, the pain management by the emergency physicians is restrained and less successful. The most common analgesic medications administered were ketamine and fentanyl, followed by piritramide.

TRIAL REGISTRATION

The study has been retrospectively registered at DRKS (DRKS00026222).

A scoping review of qualitative studies on pre-hospital analgesia administration and practice

BACKGROUND

Pain is an exceedingly common complaint in the pre-hospital setting. Despite advancements in organizational protocols and guidelines, many emergency medical services (EMS) systems still fail to provide optimal pain management. This scoping review thus aimed to map the body of qualitative literature pertaining to factors influencing pre-hospital analgesia administration and practice in order to clarify concepts and understanding as well as to identify any knowledge gaps.

METHODS

The review protocol was guided by the framework outlined by Arksey and O'Malley and ensuing recommendations made by Levac and colleagues. Five databases were searched from inception till October 26, 2021, namely MEDLINE, EMBASE, CINAHL, The Cochrane Library, and Scopus. The search strategy was developed in consultation with a medical information specialist. A total of 5848 records were screened by abstract and title by four independent researchers. 199 records were included for full text review. From these, 15 articles were eligible for thematic analysis based on pre-defined inclusion criteria.

RESULTS

Included studies found that practitioner, patient, and environmental factors influenced the administration and practice of pre-hospital analgesia. Key barriers included the difficulty in assessing pain, poor inter-professional relationship, knowledge deficits, stress and anxiety, and miscellaneous factors, such as concerns over drug-seeking behaviours. Some possible solutions were proposed, and pre-hospital EMS systems and healthcare institutions could consider bridging some of these gaps. There was a notable paucity of Asian studies, and a variety of EMS settings with different protocols and workflows were examined, hence systemic factors including guidelines and legislations cannot and should not be generalized across every healthcare system.

CONCLUSION

The factors influencing pre-hospital analgesia administration and practice remain incompletely understood. Existing tools and practice guidelines were also inadequate. This scoping review provided an overarching perspective of the extant literature, highlighting some of the significant barriers, enablers, and areas for further research.

Polish Experiences of Pain Treatment by Paramedics in relation to Good Practices of Pain Treatment: A Register-Based Study

Background

Pain is frequently encountered in the prehospital setting. The treatment of pain is one of the priority activities for paramedics.

Methods

1048576 patients under the care of EMS over a 7-month period were included in this study. Data included using pain scale and pain score, the initial diagnosis, analgesic treatment and the given drug obtained from the Ambulance Emergency Procedure Cards.

Results

The complete absence of pain was detected in 43.9% (95% CI 43.8–44.0) of patients, mild pain in 17.0% (95% CI 16.9–17.1), moderate pain in 11.6% (95% CI 11.5–11.7), and severe pain in 4.9% (95% CI 4.9–4.9) of cases. In 22.5% (95% CI 22.4–22.6), no pain rating scale was used. 98.0% (95% CI 97.9–98.1) of patients with mild, 96.1% (95% CI 96.0–96.2) with moderate, and 94.0% (95% CI 93.9–94.1) with severe pain did not receive any pain medication. The most commonly used drugs in all groups were metamizole and ketoprofen. The greatest analgesic effect was observed in the group of patients with severe pain. Pain decreased by an average of 3.2 NRS points in the drug-free group and 3.1 NRS points in the treated group. The most commonly documented diagnoses in all groups of patients were signs and diseases not classified in other groups (ICD-10 R00-R99), injuries and consequences of external causes (ICD-10 S00-T98), and diseases of the circulatory system (ICD-10 I00–I99).

Conclusions

Paramedics may use a variety of medications but use them rarely. Adding metamizole to the list of medications used by paramedics has made it one of the most commonly used drugs. Regardless of whether the drug was used or not, the analgesic effect was similar.

The Feedback Form and Its Role in Improving the Quality of Trauma Care

Background: One of the tasks of a level I trauma center is quality improvement of level II and level III regional hospitals and emergency medical services by means of continuous education and learning processes. One of the tools for this, which provides constant monitoring of the quality of treatment, is feedback. The purpose of the study was to evaluate the effect of feedback on the quality of trauma care. Methods: Retrospective cohort study comprising two periods of time, 2012-2013 and 2017-2018. The study group included physicians and pre-hospital staff who treated patients prior to referral to the level I center. Upon arrival when the trauma teams identified issues requiring improvement, they were asked to fill in feedback forms. Data on patients treated in the trauma shock room for whom feedback forms were filled out were also extracted. Results: A total of 662 feedback forms were completed, showing a significant improvement (p ˂ 0.0001). The majority of the medical personnel who received the most negative feedback were the pre-hospital staff. A significant increase was revealed in the number of feedbacks with reference to mismanagement of backboard spinal fixation, of the pre-hospital staff, in 2012-2013 compared to 2017-2018 (p < 0.001). Improvement in reducing the time of treatment in the field was also revealed, from 15.2 ± 8.3 min in 2012-2013 to 13.4 ± 7.9 min in 2017-2018. Conclusion: The findings show that feedback improves the treatment of injured patients. Furthermore, constantly monitoring the quality of treatment provided by the trauma team is vital for improvement.

Opioids for Treatment of Pre-hospital Acute Pain: A Systematic Review

INTRODUCTION

Acute pain is a frequent symptom among patients in the pre-hospital setting, and opioids are the most widely used class of drugs for the relief of pain in these patients. However, the evidence base for opioid use in this setting appears to be weak. The aim of this systematic review was to explore the efficacy and safety of opioid analgesics in the pre-hospital setting and to assess potential alternative therapies.

METHODS

The PubMed, EMBASE, Cochrane Library, Centre for Reviews and Dissemination, Scopus, and Epistemonikos databases were searched for studies investigating adult patients with acute pain prior to their arrival at hospital. Outcomes on efficacy and safety were assessed. Risk of bias for each included study was assessed according to the Cochrane approach, and confidence in the evidence was assessed using the GRADE method.

RESULTS

A total of 3453 papers were screened, of which the full text of 125 was assessed. Twelve studies were ultimately included in this systematic review. Meta-analysis was not undertaken due to substantial clinical heterogeneity among the included studies. Several studies had high risk of bias resulting in low or very low quality of evidence for most of the outcomes. No pre-hospital studies compared opioids with placebo, and no studies assessed the risk of opioid administration for subgroups of frail patients. The competency level of the attending healthcare provider did not seem to affect the efficacy or safety of opioids in two observational studies of very low quality. Intranasal opioids had a similar effect and safety profile as intravenous opioids. Moderate quality evidence supported a similar efficacy and safety of synthetic opioid compared to morphine.

CONCLUSIONS

Available evidence for pre-hospital opioid administration to relieve acute pain is scarce and the overall quality of evidence is low. Intravenous administration of synthetic, fast-acting opioids may be as effective and safe as intravenous administration of morphine. More controlled studies are needed on alternative routes for opioid administration and pre-hospital pain management for potentially more frail patient subgroups.

Barriers and facilitators to the administration of prehospital tranexamic acid: a paramedic interview study using the theoretical domains framework

BACKGROUND

Tranexamic acid (TXA) is an antifibrinolytic drug used to prevent bleeding. It was introduced as an intervention for post-traumatic haemorrhage across emergency medical services (EMS) in the UK during 2012. However, despite strong evidence of effectiveness, prehospital TXA administration rates are low. This study used the theoretical domains framework (TDF) to identify barriers and facilitators to the administration of TXA to trauma patients by EMS providers (paramedics) in the UK.

METHODS

Interviews were completed with 18 UK paramedics from a single EMS provider organisation. A convenience sampling approach was used, and interviews continued until thematic saturation was reached. Semistructured telephone interviews explored paramedics' experiences of administering TXA to trauma patients, including identifying whether or not patients were at risk of bleeding. Data were analysed inductively using thematic analysis (stage 1). Themes were mapped to the theoretical domains of the TDF to identify behavioural theory-derived barriers and facilitators to the administration of TXA to trauma patients (stage 2). Belief statements were identified and assessed for importance according to prevalence, discordance and evidence base (stage 3).

RESULTS

Barriers and facilitators to paramedics' administration of TXA to trauma patients were represented by 11 of the 14 domains of the TDF. Important barriers included a lack of knowledge and experience with TXA (Domain: Knowledge and Skills), confusion and restrictions relating to the guidelines for TXA administration (Domain: Social/professional role and identity), a lack of resources (Domain: Environmental context and resources) and difficulty in identifying patients at risk of bleeding (Domain: Memory, attention and decision processes).

CONCLUSIONS

This study presents a behavioural theory-based approach to identifying barriers and facilitators to the prehospital administration of TXA to trauma patients in the UK. It identifies multiple influencing factors that may serve as a basis for developing an intervention to increase prehospital administration of TXA.

Intranasal sufentanil compared with a classic protocol for acute pain management in an emergency department: A prospective sequential study

Introduction

Pain is a frequent complaint in the emergency department and should be measured and treated according to the existing protocols. The intranasal route offers several advantages over the oral or intravenous routes. The aim of the study was to evaluate the efficacy and safety of intranasal sufentanil as the primary opioid for acute pain in the emergency department.

Materials and methods

This was a prospective open-label sequential study in patients who presented to the emergency department with severe non-visceral pain. The control group was treated according to the current standard of care including oral or intravenous opioids whereas the intervention group was treated according to a modified protocol, including intranasal sufentanil as the only opioid. Pain intensity was measured at different time points. The occurrence of side effects, the placement of intravenous lines and the need for additional analgesia were also recorded.

Results

Pain intensity in the two groups was not comparable at baseline (8.5; IQR 8–10 in the intervention group vs 7.9; IQR 7–9.4 in the control group; p = .026). However, the median reduction of the pain score was significantly larger in the intervention group compared to the control group after 15 minutes (2.5; IQR 1.2 – 4 vs 1.6; IQR 1–2.4; p = .005) and after 30 min (4; IQR 3–5.7 vs 3.1; IQR 2–4.4; p = .02). No significant difference in pain scores between the two groups was observed after 60 min from baseline.

Conclusions

Patients receiving intranasal sufentanil for severe pain achieved better pain relief at 15 min and 30 min compared to those receiving standard care. Vertigo, nausea, vomiting and diaphoresis were side effects more frequently observed in the sufentanil group. No differences in pain relief were observed after 30 and 60 min from baseline.

Trends in prehospital pain management following the introduction of new clinical practice guidelines

BACKGROUND

Early pain treatment following injury has been shown to improve long-term outcomes, while untreated pain can facilitate higher posttraumatic stress disorder rates and worsen outcomes. Nonetheless, trauma casualties frequently receive inadequate analgesia. In June 2013, a new clinical practice guideline (CPG) regarding pain management was introduced in the Israel Defense Forces (IDF) Medical Corps, recommending oral transmucosal fentanyl citrate (OTFC) and low-dose intravenous (IV)/intramuscular ketamine. The purpose of this study was to examine trends in prehospital pain management in the IDF.

METHODS

All cases documented in the IDF trauma registry between 2008 and 2020 were examined. This study compared casualty parameters before and after the introduction of analgesia CPG in 2013. Parameters compared included demographics, injury parameters, treatment modalities, and types of analgesia provided.

RESULT

Overall, 5,653 casualties were included in our study. During the 6 years before the introduction of the CPG, 289 (26.7%) of 1,084 casualties received an analgesic treatment, compared with 1,578 (34.5%) of 4,569 casualties during the 7 years following (p < 0.001). Since its introduction, OTFC was administered to 41.8% of all casualties who received analgesia and became the most used analgesic drug in 2020 (61.1% of casualties receiving analgesia). The rate of IV morphine significantly decreased after 2013 (22.6-16%, p < 0.001).

CONCLUSION

Pain management has become more common in trauma patients' prehospital care in the IDF in recent years. There has been a significant increase in analgesia administration, with the increased use of OTFC, along with a significant reduction in the use of IV morphine. These results may be attributed to introducing a pain management CPG and implementing OTFC among medical teams. The perception of OTFC as a safe user-friendly analgesic may have contributed to its use by medical providers, increasing analgesia rates overall.

LEVEL OF EVIDENCE

Therapeutic/care management, level III.

Emergency care providers' perspectives of acute pain assessment and management in the prehospital setting, in the Western Cape, South Africa: A qualitative study

INTRODUCTION

A growing body of evidence suggests that pain knowledge and management are poor, perhaps more so in the prehospital setting. The daily challenges that emergency care providers face in dealing with prehospital pain remain unclear. This study aimed to gain a deeper understanding of acute prehospital pain assessment and management in the Western Cape, South Africa.

METHODS

A series of focus group discussions, using a constructivist paradigm and qualitative content analysis were conducted.

RESULTS

The key themes emerging from six focus groups (total 25 emergency care providers) related to the difficulties of assessing pain in this setting, factors affecting clinical reasoning in this (hostile) setting, the realities of prehospital pain care for non-advanced life support practitioners, along with emergency departments' lack of understanding and appreciation of the prehospital environment, and participants' suggestions to improve pain practice.

CONCLUSION

Several barriers and enablers, some novel, to pain assessment and management in the South African prehospital setting were identified. Our findings provide valuable insight and understanding of the challenges related to pain care prehospital providers face, in other similar prehospital settings, but also to the global body of knowledge on prehospital barriers and enablers of pain assessment and management.

The Knowledge and Educational Needs of Nurses Regarding Pain Management of Patients on Maintenance Hemodialysis: A Qualitative Study

Background:

Nurses are the first to encounter a patient in pain. A nurse’s knowledge of pain management in patients receiving hemodialysis allows them to provide optimal pain management.

Objective:

The aim of this qualitative study is to explore the experiences, perceptions, and beliefs of nurses in the hemodialysis unit regarding pain management practices and identify nurses’ educational needs to improve nurses’ pain management in practice.

Methods:

A purposive sample of 16 nurses working in four out-patient hemodialysis units in Amman, Jordan, was recruited. The data was collected through semi-structured interviews. The interviews were audio-recorded and transcribed manually for the following content analysis scheme.

Results:

The five themes and fifteen sub-categories were extracted from the nurses' experiences regarding nurses’ knowledge of pain management. The five categories that emerged from the analysis were (1) nurses’ knowledge of pain management, (2) nurses’ self-learning pain management strategy, (3) nurses’ approach to pain management, (4) patients continue to suffer unrelieved pain, (5) nurses’ educational needs.

Relevance to Clinical Practice:

This data will prove to be useful for evaluating pain management practices for patients on maintenance hemodialysis, developing educational programs for nurses working in hemodialysis units with a focus on improving pain management, and providing knowledge regarding these issues. More research is recommended among nurses for understanding pain knowledge in patients on maintenance hemodialysis.

Conclusion:

This qualitative analysis indicated that nurses are not fully aware of various strategies for pain management. Nurses’ perception of pain and pain management was found to be limited to pain assessment and some non-pharmacological management strategies. It has been revealed that nurses require educational interventions regarding pain management in practice.

Patients' experiences and wellbeing after injury: A focus group study

Background

Injury can have physical, psychological and social consequences. It is unclear which factors have an impact on patients’ wellbeing after injury. This study aimed to explore, using focus groups, patients’ experiences and wellbeing after injury and which factors, impede or facilitate patients’ wellbeing.

Methods

Trauma patients, treated in the shock room of the Elisabeth-TweeSteden Hospital, the Netherlands, participated in focus groups. Purposive sampling was used. Exclusion criteria were younger than 18 years old, severe traumatic brain injury, dementia, and insufficient knowledge of the Dutch language. The interviews were recorded, transcribed verbatim, and analyzed using coding technique open, axial, and selective coding, based on phenomenological approach.

Results

Six focus groups (3 to 7 participants) were held before data saturation was reached. In total, 134 patients were invited, 28 (21%) agreed to participate (Median age: 59.5; min. 18 –max. 84). Main reasons to decline were fear that the discussion would be too confronting or patients experienced no problems regarding the trauma or treatment. Participants experienced difficulties on physical (no recovery to pre-trauma level), psychological (fear of dying or for permanent limitations, symptoms of posttraumatic stress disorder, cognitive dysfunction), social (impact on relatives and social support) wellbeing. These are impeding factors for recovery. However, good communication, especially clarity about the injury and expectations concerning recovery and future perspectives could help patients in surrendering to care. Patients felt less helpless when they knew what to expect.

Conclusions

This is the first study that explored patients’ experiences and wellbeing after injury. Patients reported that their injury had an impact on their physical, psychological, and social wellbeing up to 12 months after injury. Professionals with the knowledge of consequences after injury could improve their anticipation on patients’ need.

Mandatory Pain Assessment in a Pediatric Emergency Department: Failure or Success?: A Retrospective Study

OBJECTIVE

Pain control is a priority in patient evaluation. Despite the proliferation of guidelines, pain is still underassessed and undertreated, especially in children. To improve efficiency and to adhere to best medical practice, our triage software was upgraded; it included mandatory pain scoring for the admission of a child to the pediatric emergency service, thereby limiting the chances of overlooking a child experiencing pain. We conducted this study to verify the effect of routine versus mandatory pain scoring on pain management under the hypothesis that mandatory pain assessment would improve reevaluation and pain treatment.

METHODS

This retrospective case-control study was conducted in our Pediatric Emergency Department (ED). We collected data with regard to pain assessment and reassessment at triage and during the entire stay in the ED, and also with regard to the drugs eventually administered. We reviewed the charts of 1274 patients admitted with the older triage software and those of 1262 patients admitted with the newer triage software (intervention group).

RESULTS

Pain was evaluated significantly more frequently in the intervention group at triage, during the medical evaluation, and at discharge. In the intervention group, a smaller percentage of patients were treated for pain at both triage and during their stay in the ED (P=0.078 and 0.048). Pain reassessment resulted lower in the intervention group (P<0.01).

DISCUSSION

Mandatory pain assessment improved the pain evaluation rate. This did not, however, translate into better treatment and management of pain in the pediatric emergency setting.

Attributes of analgesics for emergency pain relief: results of the Consensus on Management of Pain Caused by Trauma Delphi initiative

OBJECTIVES

Management of pain is suboptimal in many prehospital and emergency department settings, and European guidelines are lacking. We carried out the Consensus On Management of PAin Caused by Trauma (COMPACT) Delphi initiative to gain insights into the factors physicians consider important when selecting analgesics for trauma pain.

PATIENTS AND METHODS

A pan-European panel of experts in emergency medicine or pain (N = 31) was recruited to participate in the COMPACT Delphi initiative. In round 1, panelists supplied free-text responses to an open question about the attributes of analgesics for emergency pain relief favored by physicians. Common themes were consolidated into factors. In round 2, factors rated important by more than 75% of the panel were taken forward into round 3. In round 3, the point at which the consensus was achieved was defined a priori as at least 75% of panelists agreeing or strongly agreeing that a factor was important.

RESULTS

Twenty-nine experts participated, representing 12 European countries and with a mean (SD) of 20 (8.6) years of clinical experience. Most worked in an emergency department (79.3%). The consensus was achieved for 10 factors that were important to consider when selecting analgesics for trauma pain relief. The highest level of consensus was achieved for 'efficacy' (100%), followed by 'safety and tolerability' (96.6%), and 'ease of use' (93.1%).

CONCLUSION

These findings may facilitate the development of evidence-based guidelines supporting the provision of pain management in prehospital, emergency department, and critical care settings.

Observation of Emergency Room Nurses Managing Pediatric Pain: Care to Be Given… Care Given…

BACKGROUND

Although pain undeniably has negative consequences, pain management often remains suboptimal, particularly in the pediatric population in the emergency room (ER).

AIM

In this observational study using qualitative and quantitative methods, we investigated everyday adherence to current nursing best-practice pediatric guidelines in the ER paying particular attention to the interaction between children, parents, and nurses.

METHODS

An adapted version of the nursing observation tool for pain management was used to describe pediatric pain management provided by nurses caring for children (0-14 years old) admitted to the ER. We also assessed child-parent-nurse interactions. (The aim of the study was presented to the nurses as part of the survey on interactions without specifying the focus on pain management.) RESULTS: Forty-seven children were included (91 painful episodes) during the observation period (112 hours). There was a screening for pain in 55% of cases, and pain scales were used in 10% of cases. Analgesic treatments were administered in 75% of cases (procedural or disease-related pain). Follow-up evaluations were performed in 19% of cases. Nonpharmacologic approaches were scarcely used. The use of both helpful and nonhelpful languages were noted during interactions with children and parents. Parents' collaboration was rarely requested to help relieve their child's pain.

CONCLUSIONS

Our results show that pediatric pain management in the ER could be optimized. Parents are still not considerably involved in their child's pain management. Parents' involvement could contribute to improving pediatric pain management.

Nurse's Evaluation of a Pain Management Algorithm in Intensive Care Units

BACKGROUND

Many patients have memories of pain during intensive care unit stay. To improve pain management, practice guidelines recommend that pain management should be guided by routine pain assessment and suggest an assessment-driven, protocol-based, stepwise approach. This recommendation prompted the development of a pain-management algorithm.

AIM

Evaluate the feasibility and clinical utility of this algorithm.

DESIGN

A descriptive survey.

SETTINGS

One medical/surgical intensive care unit, one surgical intensive care unit, and one postanesthesia care unit at two hospitals in Norway.

PARTICIPANTS/SUBJECTS

Nurses working at the three units.

METHODS

A pain-management algorithm, including three pain assessment tools and a guide to pain assessment and pain management, was developed and implemented in three intensive care units. Nurses working at the three units (n = 129) responded to a questionnaire regarding the feasibility and clinical utility of the algorithm used.

RESULTS

Our results suggested that nurses considered the new pain-management algorithm to have relatively high feasibility, but somewhat lower clinical utility. Less than half of respondents thought that pain treatment in clinical practice had become more targeted using the tree pain-assessment tools (45%) and the algorithm for pain assessment and pain management (24%).

CONCLUSIONS

Pain-management algorithms may be appropriate and useful in clinical practice. However, to increase clinical utility and to achieve more targeted pain treatment, more focus on pain-treatment actions and reassessment of patients' pain is needed. Further focus in clinical practice on how to implement an algorithm and more focus on pain-treatment action and reassessment of patients' pain is needed.

Prehospital acute traumatic pain assessment and management practices in the Western Cape, South Africa: a retrospective review

BACKGROUND

Trauma is a common aetiology of acute pain in the emergency setting, and traumatic injuries have been recognised as a global public health crisis leading to numerous deaths and disabilities. This study aimed to identify the prevalence of acute pain among high acuity trauma patients presenting to a public sector emergency medical service and to describe prehospital acute traumatic pain assessment and management practices amongst emergency care providers in the Western Cape Province, South Africa.

METHODS

A retrospective review of electronic patient care reports of trauma patients treated by the South African Western Cape Emergency Medical Services between January 1 and December 31, 2017 was conducted. Stratified random sampling was utilised to select 2401 trauma patients out of 24,575 that met the inclusion criteria.

RESULTS

Of the 2401 patients reviewed, 435 (18.1%) had a pain score recorded, of which 423 (97.2%) were experiencing pain. An additional 8.1% (n = 194) of patients had pain or tenderness mentioned in the working diagnosis but no pain score noted. Eighty-one (18.6%) patients experienced mild pain, 175 (40.2%) moderate pain and 167 (38.2%) severe pain. No association was found between a pain score recorded and age group (≤ 14 versus > 14 years) (p = 0.649) or gender (p = 0.139). Only 7.6% of patients with moderate-to-severe pain and 2.8% of all trauma patients received any form of analgesic medication. No association was found between the administration of analgesia and age group (≤ 14 versus > 14 years) (p = 0.151) or gender (p = 0.054). Patients were more likely to receive analgesia if they had a pain score recorded (p < 0.001), were managed by advanced life support practitioners (p < 0.001) or had severe pain (p = 0.001).

CONCLUSION

Acute trauma pain assessment and management practices in this prehospital cohort are less well established than reported elsewhere and whether this reflects emergency care training, institutional culture, scopes of practice or analgesic resources, requires further research. Emergency medical services need to monitor and promote quality pain care, enhance pain education and ensure that all levels of emergency care providers have access to analgesic medication approved for prehospital use. Clear and rational guidelines would enable better pain management by all cadres of providers, for all levels of pain.

Acute pain assessment and management in the prehospital setting, in the Western Cape, South Africa: a knowledge, attitudes and practices survey

Background

Acute pain is frequently encountered in the prehospital setting, and therefore, a fundamental aspect of quality emergency care. Research has shown a positive association between healthcare providers’ knowledge of, and attitudes towards pain and pain management practices. This study aimed to describe the knowledge, attitudes, and practices of emergency care providers regarding acute pain assessment and management in the prehospital setting, in the Western Cape, South Africa. The specific objectives were to, identify gaps in pain knowledge; assess attitudes regarding pain assessment and management; describe pain assessment and management behaviours and practices; and identify barriers to and enablers of pain care.

Methods

A web-based descriptive cross-sectional survey was conducted among emergency care providers of all qualifications, using a face-validated Knowledge, Attitudes and Practices of Pain survey.

Results

Responses of 100 participants were included in the analysis. The survey response rate could not be calculated. The mean age of respondents was 34.74 (SD 8.13) years and the mean years’ experience 10.02 (SD 6.47). Most respondents were male (69%), employed in the public/government sector (93%) as operational practitioners (85%) with 54% of respondents having attended medical education on pain care in the last 2 years. The mean percentage for knowledge and attitudes regarding pain among emergency care providers was 58.01% (SD 15.66) with gaps identified in various aspects of pain and pain care. Practitioners with higher qualifications, more years’ experience and those who did not attend medical education on pain, achieved higher scores. Alcohol and drug use by patients were the most selected barrier to pain care while the availability of higher qualified practitioners was the most selected enabler. When asked to record pain scores, practitioners were less inclined to assign scores which were self-reported by the patients in the case scenarios. The participant dropout rate was 35%.

Conclusion

Our results suggest that there is suboptimal knowledge and attitudes regarding pain among emergency care providers in the Western Cape, South Africa. Gaps in pain knowledge, attitudes and practices were identified. Some barriers and enablers of pain care in the South African prehospital setting were identified but further research is indicated.

Inhaled Methoxyflurane versus Intravenous Morphine for Severe Trauma Pain in the Emergency Setting: Subgroup Analysis of MEDITA, a Multicenter, Randomized, Controlled, Open-Label Trial

Purpose

Opioid analgesics remain the cornerstone of treatment for severe trauma pain in the emergency setting, but there are barriers to their use. This post hoc analysis of a previously reported trial (MEDITA) investigated the efficacy and safety of low-dose methoxyflurane versus intravenous (IV) morphine for severe trauma pain.

Patients and Methods

MEDITA was a Phase IIIb, randomized, active-controlled, parallel-group, open-label study in Italian pre-hospital units and emergency departments (EudraCT: 2017-001565-25; NCT03585374). Adult patients (N=272) with moderate-to-severe trauma pain (score ≥4 on the Numerical Rating Scale [NRS]) were randomized 1:1 to inhaled methoxyflurane (3 mL) or standard analgesic treatment (SAT; IV paracetamol 1g or ketoprofen 100mg for moderate pain [NRS 4-6] and IV morphine 0.1mg/kg for severe pain [NRS ≥7]). Analyses were performed for the severe pain subgroup. The primary efficacy variable was the overall change from baseline in visual analog scale (VAS) pain intensity at 3, 5 and 10min post-randomization. Non-inferiority of methoxyflurane versus morphine was concluded if the upper 95% confidence interval (CI) for the treatment difference was <1; superiority was concluded if the upper 95% CI was <0.

Results

Ninety-three patients (methoxyflurane: 49; SAT: 44) were included in the severe pain intention-to-treat population. The reduction in VAS pain intensity over the first 10min was superior for methoxyflurane versus morphine (adjusted mean treatment difference: -5.54mm; 95% CI: -10.49, -0.59mm; p=0.029). Median time to onset of pain relief was 9min for methoxyflurane and 15min for morphine. Patients rated treatment efficacy and physicians rated treatment practicality "Excellent" or "Very good" for more methoxyflurane-treated patients (42.8% and 67.3%) than morphine-treated patients (18.1% and 22.8%). Adverse events, all non-serious, were reported in 20.4% of methoxyflurane-treated patients and in 4.8% of morphine-treated patients.

Conclusion

Methoxyflurane provided superior short-term pain relief to IV morphine in patients with severe trauma pain and offers an effective non-narcotic treatment option.

How can pain management in the emergency department be improved? Findings from multiple case study analysis of pain management in three UK emergency departments

INTRODUCTION

Inadequate pain management in EDs is a worldwide problem, yet there has been little progress in understanding how pain management can be improved. There is only weak evidence and limited rationale to support interventions to improve pain management. We used naturalistic, qualitative methods to understand the factors that influence how pain is managed within the adult ED.

METHODS

We used a multiple case study design incorporating 143-hour non-participant observation, documentary analysis and semistructured interviews with 37 staff and 19 patients at three EDs in the North of England between 2014 and 2016. We analysed data using thematic analysis.

RESULTS

Our analysis demonstrated that pain management was not well aligned with the core priorities of the ED and was overlooked when other works took priority. We identified that (1) pain management was not perceived to be a key organisational priority for which staff were held accountable and staff had limited awareness of their performance, (2) pain management was not a core component of ED education and training, (3) ED processes and structures were not aligned with pain management and pain reassessment was overlooked unless staff escalated pain management outside of normal processes and (4) staff held embedded beliefs that conceptualised pain management as distinct from core priorities and limited their capacity to improve. However, EDs were able to improve pain management by aligning processes of pain management with other core works, particularly patient flow (eg, nurse-initiated analgesia at triage).

IMPLICATIONS

EDs may be able to improve pain management by ensuring pain management processes align with key ED priorities. Undertaking multifaceted changes to structures and processes may enable staff to improve pain management and develop a culture in which pain management can be prioritised more easily. Future interventions need to be compatible with the wider work of the ED and enable patient flow in order to be adopted and maintained.

Development of a national medical leadership competency framework: the Dutch approach

BACKGROUND

The concept of medical leadership (ML) can enhance physicians' inclusion in efforts for higher quality healthcare. Despite ML's spiking popularity, only a few countries have built a national taxonomy to facilitate ML competency education and training. In this paper we discuss the development of the Dutch ML competency framework with two objectives: to account for the framework's making and to complement to known approaches of developing such frameworks.

METHODS

We designed a research approach and analyzed data from multiple sources based on Grounded Theory. Facilitated by the Royal Dutch Medical Association, a group of 14 volunteer researchers met over a period of 2.5 years to perform: 1) literature review; 2) individual interviews; 3) focus groups; 4) online surveys; 5) international framework comparison; and 6) comprehensive data synthesis.

RESULTS

The developmental processes that led to the framework provided a taxonomic depiction of ML in Dutch perspective. It can be seen as a canonical 'knowledge artefact' created by a community of practice and comprises of a contemporary definition of ML and 12 domains, each entailing four distinct ML competencies.

CONCLUSIONS

This paper demonstrates how a new language for ML can be created in a healthcare system. The success of our approach to capture insights, expectations and demands relating leadership by Dutch physicians depended on close involvement of the Dutch national medical associations and a nationally active community of practice; voluntary work of diverse researchers and medical practitioners and an appropriate research design that used multiple methods and strategies to circumvent reverberation of established opinions and conventionalisms.

IMPLICATIONS

The experiences reported here may provide inspiration and guidance for those anticipating similar work in other countries to develop a tailored approach to create a ML framework.

Effects of the Introduction of Intranasal Fentanyl on Reduction of Pain Severity Score in Children: An Interrupted Time-Series Analysis

OBJECTIVES

Children are at risk of inadequate analgesia due to paramedics' inexperience in assessing children and challenges in administering analgesics when the patient is distressed and uncooperative. This study reports on the outcome of a change to practice guidelines that added intranasal fentanyl and intramuscular morphine within a large statewide ambulance service.

METHODS

This retrospective study included patients younger than 15 years treated by paramedics between January 2008 and December 2011. The primary outcome of interest was the proportion of patients having a 2/10 or greater reduction in pain severity score using an 11-point Verbal Numeric Rating Scale before and after the intervention. Segmented regression analysis was used to estimate the effect of the intervention over time. A multiple regression model calculated odds ratios with 95% confidence intervals.

RESULTS

A total of 92,378 children were transported by paramedics during the study period, with 9833 cases included in the analysis. The median age was 11 years; 61.6% were male. Before the intervention, 88.1% (n = 3114) of children receiving analgesia had a reduction of pain severity of 2 or more points, with 94.2% (n = 5933) achieving this benchmark after intervention (P < 0.0001). The odds of a reduction in pain of 2 or more points increased by 1.01 per month immediately before the intervention and 2.33 after intervention (<0.0001).

CONCLUSIONS

This large study of a system-wide clinical practice guideline change has demonstrated a significant improvement in the outcome of interest. However, a proportion of children with moderate to severe pain did not receive analgesia.

Pain is vital in resuscitation in trauma

Implementation of the ATLS algorithm has remarkably improved the resuscitation of trauma patients and has significantly contributed to the systematic management of multi-trauma patients. However, pain remains the most prevalent complaint in trauma patients, and can induce severe complications, further deterioration of health, and death of the patient. Providing appropriate and timely pain management to these patients prompts early healing, reduces stress response, shortens hospital Length of Stay (LOS), diminishes chronic pain, and ultimately reduces morbidity and mortality. Pain has been proposed to be evaluated as the fifth vital sign and be recorded in the vital sign charts in order to emphasize the importance of pain on short- and long-term outcomes of the patients. However, although the quality of pain treatment seems to be improving we believe that pain has been underestimated in trauma. This article aims to provide evidence for the importance of pain in trauma, to support its management in the emergency setting and the acute phase of patients’ resuscitation, and to emphasize on the necessity to introduce the letter P (pain) in the ATLS alphabet.

Caring science research in the ambulance services: an integrative systematic review

BACKGROUND

The ambulance services are associated with emergency medicine, traumatology and disaster medicine, which is also reflected in previous research. Caring science research is limited and, since no systematic reviews have yet been produced, its focus is unclear. This makes it difficult for researchers to identify current knowledge gaps and clinicians to implement research findings.

AIM

This integrative systematic review aims to describe caring science research content and scope in the ambulance services.

DATA SOURCES

Databases included were MEDLINE (PubMed), CINAHL, Web of Science, ProQDiss, LibrisDiss and The Cochrane Library. The electronic search strategy was carried out between March and April 2015. The review was conducted in line with the standards of the PRISMA statement, registration number: PROSPERO 2016:CRD42016034156.

REVIEW METHODS

The review process involved problem identification, literature search, data evaluation, data analysis and reporting. Thematic data analysis was undertaken using a five-stage method. Studies included were evaluated with methodological and/or theoretical rigour on a 3-level scale, and data relevance was evaluated on a 2-level scale.

RESULTS

After the screening process, a total of 78 studies were included. The majority of these were conducted in Sweden (n = 42), fourteen in the United States and eleven in the United Kingdom. The number of study participants varied, from a case study with one participant to a survey with 2420 participants, and 28 (36%) of the studies were directly related to patients. The findings were identified under the themes: Caregiving in unpredictable situations; Independent and shared decision-making; Public environment and patient safety; Life-changing situations; and Ethics and values.

CONCLUSION

Caring science research with an explicit patient perspective is limited. Areas of particular interest for future research are the impact of unpredictable encounters on openness and sensitivity in the professional-patient relation, with special focus on value conflicts in emergency situations.

Oral Diclofenac Potassium Versus Intravenous Acetaminophen in Acute, Isolated, Closed-Limb Trauma

Pain control is an important concern in limb trauma. The most ideal agent for this purpose varies among different hospitals. The objective of this study was to compare the analgesic effect of oral diclofenac potassium versus intravenous acetaminophen in patients with limb trauma. This was a double-blind randomized clinical trial conducted on 60 adult patients. Oral diclofenac potassium (50 mg) was given in Group D, and intravenous acetaminophen (1 g in 500 ml normal saline over 20 min) was administered in Group A. Patients' pain scores (visual analogue scale) were recorded and compared at baseline, 5, 15, 30, 60 min, and 4 hr after drug administration. The mean age was 42.62 ± 15.42 and 38.04 ± 17.48 years in Group A and Group D, respectively. No significant change was observed between the 2 groups (p = 0.11). In this study, both drugs could decrease the pain score effectively and safely in isolated limb trauma.

Assessment of Acute Pain Management and Associated Factors among Emergency Surgical Patients in Gondar University Specialized Hospital Emergency Department, Northwest Ethiopia, 2018: Institutional Based Cross-Sectional Study

Background

Adequate pain management has led to increased comfort in emergency patients, reducing morbidity and improving long term outcomes. Different pain management modalities have been applied in the emergency department among which systemic analgesia is commonly used by preceding a nerve block. Several factors have been associated with poor pain management in low resource setting areas. We aimed to determine pain management modalities and associated factors among emergency surgical patients.

Patients and Methods

After obtaining ethical approval from Ethical Review Committee, 203 volunteer patients were enrolled. Institutional based cross-sectional prospective study was conducted from April to May 2018 in Gondar University Specialized Hospital Emergency Department. The severity of pain was measured through Numerical Rating Scale and statistical analysis was performed using SPSS statistical package version 23. Descriptive statistics cross-tab and binary logistics were performed to identify factors related to pain management in emergency department.

Results

A total of 203 patients, 138 (68%) males and 65 (32%) females with response rate of 94%, participated in this study. Among them, 66% patients received analgesia within two hours of ED presentation with a mean ± SD of 61.0 ± 34.1 minutes. 70.4 % of patients complained of moderate and severe pain after receiving analgesia. There was a significant difference between trauma and nontrauma patients in mean time of analgesia receiving and residual pain severity (p < 0.001). Age, trauma, physician pain assessment, and severity of pain were the predicting factors for analgesia delivery.

Conclusion

The overall practice of pain management in Gondar University Specialized Hospital Emergency Department was not adequate. Therefore, it is vital to implement an objective pain assessment method and documentation of the pain severity to improve pain management practice.

Retour d’expérience sur l’utilisation du méthoxyflurane aux urgences

L’oligoanalgésie chez le patient traumatisé aux urgences est une situation fréquente du fait de la complexité de la prise en charge de la douleur. L’une des solutions les mieux décrites à ce problème est l’utilisation d’analgésiques dès l’admission du patient. Ce type de protocole est à privilégier notamment en cas de filière de prise en charge rapide au sein des urgences. Le méthoxyflurane est un éther halogéné volatil utilisé en médecine. Son inhalation produit une analgésie supérieure au placebo. Du fait de sa rapidité d’action, de sa facilité d’emploi et de ses propriétés antalgiques, le méthoxyflurane doit faire partie de l’arsenal des thérapeutiques antalgiques aux urgences. Aux urgences du CHU de Grenoble-Alpes, nous privilégions l’utilisation du méthoxyflurane au sein d’un protocole d’analgésie multimodale du patient adulte traumatisé. Dans cette indication, le méthoxyflurane permet d’amorcer l’analgésie et de faire le pont jusqu’à ce que les autres thérapeutiques soient efficaces.

A Review of the Burden of Trauma Pain in Emergency Settings in Europe

Trauma pain represents a large proportion of admissions to emergency departments across Europe. There is currently an unmet need in the treatment of trauma pain extending throughout the patient journey in emergency settings. This review aims to explore these unmet needs and describe barriers to the delivery of effective analgesia for trauma pain in emergency settings. A comprehensive, qualitative review of the literature was conducted using a structured search strategy (Medline, Embase and Evidence Based Medicine Reviews) along with additional Internet-based sources to identify relevant human studies published in the prior 11 years (January 2006-December 2017). From a total of 4325 publications identified, 31 were selected for inclusion based on defined criteria. Numerous barriers to the effective treatment of trauma pain in emergency settings were identified, which may be broadly defined as arising from a lack of effective pain management pan-European and national guidelines, delayed or absent pain assessment, an aversion to opioid analgesia and a delay in the administration of analgesia. Several commonly used analgesics also present limitations in the treatment of trauma pain due to the routes of administration, adverse side effect profiles, pharmacokinetic properties and suitability for use in pre-hospital settings. These combined barriers lead to the inadequate and ineffective treatment of trauma pain for patients. An unmet need therefore exists for novel forms of analgesia, wider spread use of available analgesic agents which overcome some limitations associated with several treatment options, and the development of protocols for pain management which include patient assessment of pain.Funding: Mundipharma International Ltd.

Perspectives on clinical use of bioimpedance in hemodialysis: focus group interviews with renal care professionals

Background

Inadequate volume control may be a main contributor to poor survival and high mortality in hemodialysis patients. Bioimpedance measurement has the potential to improve fluid management, but several dialysis centers lack an agreed fluid management policy, and the method has not yet been implemented. Our aim was to identify renal care professionals’ perceived barriers and facilitators for use of bioimpedance in clinical practice.

Methods

Qualitative data were collected through four focus group interviews with 24 renal care professionals: dieticians, nephrologists and nurses, recruited voluntarily from a nation-wide selection of hemodialysis centers, having access to a bioimpedance-device. The participants were connected to each other and a moderator via equipment for telemedicine and the sessions were recorded. The interviews were semi-structured, focusing on the participants’ perceptions of use of bioimpedance in clinical practice. Thematic content analysis was performed in consecutive steps, and data were extracted by employing an inductive, interactive, comparative process.

Results

Several barriers and facilitators to the use of bioimpedance in clinical practice were identified, and a multilevel approach to examining barriers and incentives for change was found to be applicable to the ideas and categories that arose from the data. The determinants were categorized on five levels, and the different themes of the levels illustrated with quotations from the focus groups participants.

Conclusions

Determinants for use of bioimpedance were identified on five levels: 1) the innovation itself, 2) the individual professional, 3) the patient, 4) the social context and 5) the organizational context. Barriers were identified in the areas of credibility, awareness, knowledge, self-efficacy, care processes, organizational structures and regulations. Facilitators were identified in the areas of the innovation’s attractiveness, advantages in practice, and collaboration. Motivation, team processes and organizational capacities appeared as both barriers and facilitators.

Electronic supplementary material

The online version of this article (10.1186/s12882-018-0907-4) contains supplementary material, which is available to authorized users.

Registered nurses' own experience of using a nurse-initiated pain protocol based on their working experience

AIMS AND OBJECTIVES

To explore registered nurses' (RNs) own experience of using the nurse-initiated pain protocol (NIPP) in the emergency department (ED) based on their working experience.

BACKGROUND

Pain is known to be one of the most common symptoms among adult patients seeking care at the ED. Several strategies aiming to improve pain management have been developed. Despite some improvements in pain management using NIPP, a large number of patients continue to have inadequate pain treatment when cared for in EDs.

DESIGN AND METHOD

A cross-sectional study design based on a questionnaire was used. The variable working experience was based on a theory that experience will make a change in RNs' knowledge. Descriptive statistics and Pearson's chi-square tests were used for analysing quantative data. Qualitative data were analysed by summative content analysis.

RESULTS

Seventy RNs answered the questionnaire (response rate 42%) and 61% considered the NIPP adequate to relieve patients' acute pain at the ED. No significant difference was found on how the RNs used the NIPP. However, qualitative data showed that more experienced RNs adapt the NIPP according to the patients' needs in a higher extent.

CONCLUSION

A majority of the RNs consider the NIPP to be adequate to relieve patients' acute pain in the ED. An increase in working experience showed an impact on how the NIPP was used, with an increase in pain management that is personalised depending on individual patients' needs. The RNs used several alternatives to both dosage and type of medication when the ED becomes crowded.

RELEVANCE TO CLINICAL PRACTICE

Registered nurses' working experience should be considered when planning nursing schedules to be better able to meet patients' needs. Guidelines should be developed and evaluated by both healthcare professionals and patients.

Demographic, Clinical, and Health System Characteristics Associated With Pain Assessment Documentation and Pain Severity in U.S. Military Patients in Combat Zone Emergency Departments, 2010-2013

Emergency department (ED) pain assessment documentation in trauma patients is critical to ED pain care. This retrospective, cross-sectional study used trauma registry data to evaluate U.S. military combat zone trauma patients injured between 2010 and 2013 requiring ≥ 24-hr inpatient care. Study aims were to identify the frequency of combat zone ED pain assessment documentation and describe pain severity. Secondary aims were to construct statistical models to explain variation in pain assessment documentation and pain severity.Pain scores were documented in 60.5% (n = 3,339) of the 5,518 records evaluated. The proportion of records with ED pain scores increased yearly. Pain assessment documentation was associated with documentation of ED vital signs, comprehensive facility, more recent year, prehospital (PH) heart rate of 60-100 beats/min, ED Glasgow Coma Scale score of 15 vs. 14, blunt trauma, and lower injury severity score (ISS).Pain severity scores ranged from 0 to 10; mean = 5.5 (SD = 3.1); median = 6. Higher ED pain scores were associated with Army service compared with Marine Corps, no documented PH vital signs, higher PH pain score, ED respiratory rate < 12 or >16, moderate or severe ISS compared with minor ISS, treatment in a less-equipped facility, and injury in 2011 or 2012 vs. 2010. The pain severity model explained 20.4% of variance in pain severity.Overall, frequency of pain assessment documentation in combat-zone EDs improved yearly, but remained suboptimal. Pain severity was poorly predicted by demographic, clinical, and health system variables available from the trauma registry, emphasizing the importance of individual assessment.

Exploring how nurses assess, monitor and manage acute pain for adult critically ill patients in the emergency department: protocol for a mixed methods study

BACKGROUND

Many critically ill patients experience moderate to severe acute pain that is frequently undetected and/or undertreated. Acute pain in this patient cohort not only derives from their injury and/or illness, but also as a consequence of delivering care whilst stabilising the patient. Emergency nurses are increasingly responsible for the safety and wellbeing of critically ill patients, which includes assessing, monitoring and managing acute pain. How emergency nurses manage acute pain in critically ill adult patients is unknown. The objective of this study is to explore how emergency nurses manage acute pain in critically ill patients in the Emergency Department.

METHODS

In this paper, we provide a detailed description of the methods and protocol for a multiphase sequential mixed methods study, exploring how emergency nurses assess, monitor and manage acute pain in critically ill adult patients. The objective, method, data collection and analysis of each phase are explained. Justification of each method and data integration is described.

DISCUSSION

Synthesis of findings will generate a comprehensive picture of how emergency nurses' perceive and manage acute pain in critically ill adult patients. The results of this study will form a knowledge base to expand theory and inform research and practice.

A description of pharmacological analgesia administration by public sector advanced life support paramedics in the City of Cape Town

INTRODUCTION

Emergency Medical Services are ideally placed to provide relief of acute pain and discomfort. The objectives of this study were to describe pre-hospital pain management practices by Emergency Medical Services in the Western Cape, South Africa.

METHODS

A retrospective, descriptive survey was undertaken of analgesic drug administration by advanced life support paramedics. Patient care records generated in the City of Cape Town during an 11-month period containing administrations of morphine, ketamine, nitrates and 50% nitrous oxide/oxygen were randomly sampled. Variables studied were drug dose, dose frequency, and route of administration, patient age, gender, disorder and call type as well as qualification and experience level of the provider.

RESULTS

A total of 530 patient care records were included (n = 530). Morphine was administered in 371 (70%, 95% CI 66-74) cases, nitrates in 197 (37%, 95% CI 33-41) and ketamine in 9 (1.7%, 95% CI 1-3) cases. A total of 5 mg or less of morphine was administered in 278 (75%, 95% CI 70-79) cases, with the median dose being 4 mg (IQR 3-6). Single doses were administered to 268 (72.2%, 95% CI 67-77) morphine administrations, five (56%, 95% CI 21-86) ketamine administrations and 161 (82%, 95% CI 76-87) of nitrate administrations. Chest pain was the reason for pain management in 226 (43%) cases. Advanced Life Support Providers had a median experience level of two years (IQR 2-4).

DISCUSSION

Pre-hospital acute pain management in the Western Cape does not appear to conform to best practice as Advanced Life Support providers in the Western Cape use low doses of morphine. Chest pain is an important reason for drug administration in acute pre-hospital pain. Multimodal analgesia is not a feature of care in this pre-hospital service. The development of a Clinical Practice Guideline for and training in pre-hospital pain should be viewed as imperative.

Pain management of trauma patients in the emergency department: a study in a public hospital in Iran

BACKGROUND

Pain is a common problem which the patients in emergency departments (ED) face, especially trauma patients under treatment may suffer from physical, psychological and ethical issues. The purpose of this study was to evaluate traumatic pain management in the emergency department at a public hospital in Iran in 2014.

METHODS

This observational prospective study was conducted on 450 trauma patients admitted to a trauma emergency department. The tool used in this study has three parts: demographic data, data of trauma, and VRS (Verbal Rating Scales) score at a 7-point scale-at the arrival time to 4h later. The statistical analysis was conducted by using Mann-Whitney and Kruskal-Wallis tests, repeated measures, survival analysis, and multiple regression analysis.

RESULTS

The majority of the samples were male (83.3%) with the mean age of 35.2years. The patients mostly suffered from contusions and strains (42.4%). The majority of the patients [274 patients (60.8%)] received no intervention for pain relief and only 60 patients (13.3%) received analgesics. The mean time period of the first analgesic utilization was 41 (±20.4) minutes. Pain in admission, pain assessment, and receiving intervention could explain the 32% of pain reduction. No other variables such as age, sex, education, kind of trauma, and the shift of admission were involved in pain reduction.

CONCLUSIONS

This research study demonstrated that comprehensive, adequate pain management remains an obscure goal within the emergency nursing setting. There is a need to undertake further research and develop educational programs on effective analgesic practice in pain management.

An assessment of the future impact of alternative technologies on antibiotics markets

BACKGROUND

The increasing threat of antimicrobial resistance combined with the paucity of new classes of antibiotics represents a serious public health challenge. New treatment technologies could, in theory, have a significant impact on the future use of traditional antibiotics, be it by facilitating rational and responsible use or by product substitution in the existing antibiotics markets, including by reducing the incidence of bacterial infections through preventative approaches. The aim of this paper is to assess the potential of alternative technologies in reducing clinical use of and demand for antibiotics, and to briefly indicate which segments of the antibiotics market that might be impacted by these technologies.

METHODS

An initial mapping exercise to identify the alternative technologies was followed by a review of relevant published and grey literature (n = 52). We also carried out stakeholder engagement activities by a round-table discussion with infectious disease specialists and a multi-criteria decision analysis exercise with pharmaceutical industry experts.

RESULTS

Ten alternative technologies were identified and analyzed for their potential impact on the antibiotics market. Of these, rapid point-of-care diagnostics, vaccines, fecal microbiota transplantation, and probiotics were considered to have a "high" or "medium" potential impact over a 10-20 year horizon. Therapeutic antibodies, antibiotic biomaterials, bacteriophages, antimicrobial nanoparticles, antimicrobial peptides, and anti-virulence materials were rated as having "low" potential impact.

CONCLUSION

Despite the apparent potential of the most promising alternative technologies to reduce demand, that reduction will likely only happen in limited segments of the antibiotics market or, in the case of preventing community acquired streptococcal infections by vaccination, in a low-price generics market segment. Thus, alternative technologies are not expected to represent any disincentive to antibiotics developers. Finally, it is unlikely that alternative technologies will displace the need for new classes, and sub-classes, of antibiotics in the short and medium terms.

Implementation, context and complexity

BACKGROUND

Context is a problem in research on health behaviour change, knowledge translation, practice implementation and health improvement. This is because many intervention and evaluation designs seek to eliminate contextual confounders, when these represent the normal conditions into which interventions must be integrated if they are to be workable in practice.

DISCUSSION

We present an ecological model of the ways that participants in implementation and health improvement processes interact with contexts. The paper addresses the problem of context as it affects processes of implementation, scaling up and diffusion of interventions. We extend our earlier work to develop Normalisation Process Theory and show how these processes involve interactions between mechanisms of resource mobilisation, collective action and negotiations with context. These mechanisms are adaptive. They contribute to self-organisation in complex adaptive systems.

CONCLUSION

Implementation includes the translational efforts that take healthcare interventions beyond the closed systems of evaluation studies into the open systems of 'real world' contexts. The outcome of these processes depends on interactions and negotiations between their participants and contexts. In these negotiations, the plasticity of intervention components, the degree of participants' discretion over resource mobilisation and actors' contributions, and the elasticity of contexts, all play important parts. Understanding these processes in terms of feedback loops, adaptive mechanisms and the practical compromises that stem from them enables us to see the mechanisms specified by NPT as core elements of self-organisation in complex systems.

Implementation, context and complexity

BACKGROUND

Context is a problem in research on health behaviour change, knowledge translation, practice implementation and health improvement. This is because many intervention and evaluation designs seek to eliminate contextual confounders, when these represent the normal conditions into which interventions must be integrated if they are to be workable in practice.

DISCUSSION

We present an ecological model of the ways that participants in implementation and health improvement processes interact with contexts. The paper addresses the problem of context as it affects processes of implementation, scaling up and diffusion of interventions. We extend our earlier work to develop Normalisation Process Theory and show how these processes involve interactions between mechanisms of resource mobilisation, collective action and negotiations with context. These mechanisms are adaptive. They contribute to self-organisation in complex adaptive systems.

CONCLUSION

Implementation includes the translational efforts that take healthcare interventions beyond the closed systems of evaluation studies into the open systems of 'real world' contexts. The outcome of these processes depends on interactions and negotiations between their participants and contexts. In these negotiations, the plasticity of intervention components, the degree of participants' discretion over resource mobilisation and actors' contributions, and the elasticity of contexts, all play important parts. Understanding these processes in terms of feedback loops, adaptive mechanisms and the practical compromises that stem from them enables us to see the mechanisms specified by NPT as core elements of self-organisation in complex systems.

Prehospital Opioid Administration in the Emergency Care of Injured Children

OBJECTIVE

Prior studies have identified provider and system characteristics that impede pain management in children, but no studies have investigated the effect of changing these characteristics on prehospital opioid analgesia. Our objectives were to determine: 1) the frequency of opioid analgesia and pain score documentation among prehospital pediatric patients after system wide changes to improve pain treatment, and 2) if older age, longer transport times, the presence of vascular access and pain score documentation were associated with increased prehospital administration of opioid analgesia in children.

METHODS

This was a retrospective cross-sectional study of pediatric patients aged 3-18 years assessed by a single EMS system between October 1, 2011 and September 30, 2013. Prior to October 2011, the EMS system had implemented 3 changes to improve pain treatment: (1) training on age appropriate pain scales, (2) protocol changes to allow opioid analgesia without contacting medical control, and (3) the introduction of intranasal fentanyl. All patients with working assessments of blunt, penetrating, lacerating, and/or burn trauma were included. We used descriptive statistics to determine the frequency of pain score documentation and opioid analgesia administration and logistic regression to determine the association of age, transport time, and the presence of intravenous access with opioid analgesia administration.

RESULTS

Of the 1,368 eligible children, 336 (25%) had a documented pain score. Eleven percent (130/1204) of children without documented contraindications to opioid administration received opioids. Of the children with no documented pain score and no protocol exclusions, 9% (81/929) received opioid analgesia, whereas 18% (49/275) with a documented pain score ≥4 and no protocol exclusions received opioids. Multivariate analysis revealed that vascular access (OR = 11.89; 95% CI: 7.33-19.29), longer patient transport time (OR = 1.07; 95% CI: 1.04-1.11), age (OR 0.93; 95% CI: 0.88-0.98) and pain score documentation (OR 2.23; 95% CI: 1.40-3.55) were associated with opioid analgesia.

CONCLUSIONS

Despite implementation of several best practice recommendations to improve prehospital pain treatment, few children have a documented pain score and even fewer receive opioid analgesia. Children with longer transport times, successful IV placement, and/or documentation of pain score(s) were more likely to receive prehospital analgesia.

Is pain really undertreated? Challenges of addressing pain in trauma patients during prehospital transport and trauma resuscitation

BACKGROUND

Prior research has documented the inadequacy of pain management for trauma patients in the emergency department (ED), with rates of pain assessment and opioid administration averaging about 50%. Such rates, however, may be misleading and do not adequately capture the complexity of pain management practices in a trauma population. The goal of the study was to determine if pain was undertreated at the study hospital or if patient acuity explained the timing and occurrence of pain treatment in the prehospital setting and the ED.

METHODS

A retrospective study was performed at a Level 1 adult trauma centre in the Midwest. The trauma registry was used to identify patients who received a trauma activation during the study period (June-November 2012; N=313). Using the first set of patient vitals and ISS, patients were grouped into three categories: physiologically stable with low injury severity (n=132); physiologically stable with moderate to severe injury (n=122); and physiologically unstable with severe injury (n=56). Differences were assessed with Kruskal-Wallis and chi-square tests.

RESULTS

Patients who were physiologically unstable were the least likely to receive a standardised pain assessment and the least likely to receive an opioid in the ED. Patients who were physiologically stable at entry to the ED but sustained a severe injury were the most likely to receive an opioid. Time to first pain assessment and time to first opioid did not differ by patient acuity.

CONCLUSIONS

Results confirm that patient acuity greatly affects the ability to effectively and appropriately manage pain in the initial hours after injury. This study contributes to the literature by noting areas for improvement but also in explaining why delaying pain treatment may be appropriate in certain patient populations.